EmailMe Form - North Central Ballet Summer Workshop 2022

Student Name

First Last

Student Age *

Date of Birth *

Parent Name *

First Last

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Email *

Phone Number *

### - ### - ####

Emergency Contact *

First Last

Emergency Contact Phone *

### - ### - ####

Full Program June 20-July 15

Pay Online ($2205.00)

Pay by Check ($2100)

Week 1- June 20-24

Pay by Check ($750.00)

Pay Online ($787.50)

Week 2- June 27-July 1

Pay by Check ($750.00)

Pay Online ($787.50)

Week 3- July 5-9

Pay by Check ($750.00)

Pay Online ($787.50)

Week 4- July 11-15

Pay by Check ($750.00)

Pay Online ($787.50)

Previous Training/Current Level *

Years en pointe *